In 2020, 2.9% of the US population identified as American Indian or Alaskan Native (AI/AN)** alone or in combination increasing from 5.2 million in 2010 to 9.7 million in 2020.1 Importantly AI/AN represents a vast number of indigenous peoples (e.g., tribal nations). The United States Bureau of Indian Affairs recognizes 574 Tribal entities which are eligible for funding and services by virtue of their status as Indian Tribes. Such diversity speaks to the heterogeneity of culture present among the indigenous populations of North America and is important context when considering the AI/AN as a collective ethnicity.
Thus, the Western concept of mental health illnesses may not correspond with the beliefs and interpretations of AI/AN cultures. The words “depressed” and “anxious” are absent from some native languages where alternative expressions such as “ghost sickness” or “heartbreak syndrome” are present.2 Many tribal cultures embrace the notions of interconnectedness balancing the mind, body, and spirit highlighting one’s well-being is entwined with cultural identity, family, and a connection to the past.3
The shared history of trauma caused by colonialism for the indigenous and native populations is believed to be a factor in the reports of 2.5 times more experiences of serious psychological distress in AI/AN populations compared to non-indigenous populations.4 Although numbers vary by tribe, the suicide death rate for AI/AN populations between the ages of 15-19 is more than double than all other racial ethnic groups.5 Tragically, when compared to other ethnic groups by sex AI/AN females and males showed the highest increases in deaths by suicide in recent decades at 139% and 71% respectively.10 Elevated risk factors of suicide may be influenced by the fact the 26% of AI/AN live in poverty,2 as well as the higher rates of alcohol and drug abuse compared to all other ethnic groups, and the impacts of "historical trauma, alienation, acculturation, discrimination, community violence, lack of access to care, and exposure to suicide." 5 Recent prospective data indicates that by an average age of 26 the cumulative rates of psychiatric disorder was 77.% among a large sample of AI young adults.11 Importantly, authors note that this estimate may be an underestimate due to assessing selected disorder and may also be impacted by validity concerns of diagnostic interviews that were not developed for use in indigenous populations.11 It is important to note that AI/AN have also demonstrated disproportionately high levels of positive mental health despite being impacted by disparities mental illness.12 These finding indicate that AI communities are impacted by a disproportionately large risk burden which includes factors such as historical trauma, discrimination, and sociopolitical disadvantage.
**NOTE: collective terms such as American Indian/Alaska Native (AIAN), Native American, Native, Indigenous, First Peoples, and others have often been used interchangeably to refer to indigenous populations of North America. As is noted herein, within the United State Alone 574 distinct sovereign Tribal nations are federally recognized representing tremendous heterogeneity. Regarding collective terminology it is most respectful to use the term that either an individual and/or a community prefers. For the purposes of the [following/above] information [American Indian/Alaska Native (AI/AN)] is used for linguistic consistency with U.S. census self-report categories.
Access to mental health care services is often limited by nature of the rural, isolated location of federally recognized indigenous communities. In 2011, mental health services are reportedly available within 82% of tribal facilities.6 Those facilities report barriers to access preventing treatment including half of the facilities reporting physical barriers, one-third reporting persona and social barriers, and nearly one-third reporting economic barriers.6 To further exacerbate the disproportionate barriers to access, while these services do exist they are primarily provided on reservations and consequently 78% of AI/AN live outside of tribal areas7 and 21% lack health insurance coverage.3
Research suggests that indigenous persons with anxiety and depression may seek help from other sources including traditional and spiritual healers.3 There is a scarcity of available ethnically similar providers “approximately 101 American Indian and Alaska Native mental health providers (psychiatrists, psychologists, social workers, psychiatric nurses, and counselors) are available per 100,000 members of this ethnic group… [and only] an estimated 29 psychiatrists in the United States were of Indian or Native heritage.” 8 Mental health programs for indigenous persons should address community and traditional knowledge, potentially incorporating structural aspects of CBT, 9 to approach healing. Notably, validity of many evidence-based treatments in AI/AN communities is an open question. Recent efforts have turned to cultural adaptation of evidence-based protocols to alleviate concerns of lack of efficacy in specific cultural populations. Although valuable and necessary, rigorous evaluation for establishing validity of EBTs in AI peoples (adapted or not) is resource intensive and represents a large potential burden on under-resourced mental health service systems and such work should be conducted with care and consideration.13
It is important to find a provider who demonstrates cultural competence - which describes the ability of healthcare systems to provide care to patients with diverse values, beliefs and behaviors and taking into account their social, cultural and linguistic needs. Unfortunately, research has shown lack of cultural competence in mental health care, which results in misdiagnosis and inadequate treatment. When meeting with your provider, ask questions to get a sense of their level of cultural sensitivity, such as whether they have treated Native Americans, received training in cultural competence, and how they plan to take your beliefs and practices into account when suggesting treatment. Learn more about finding the right therapist.
- Understanding the Cracks: What COVID-19 Means for the Mental Health of the Marginalized in the United States and Opportunities for Response, blog post by Anna Bartuska BS/BA, Derri Shtasel, MD, MPH, Luana Marques, PhD
- Persistent Trauma of Systemic Racial Inequities and the Perils of COVID-19, blog post by Mbemba Jabbi, PhD and Kathariya Mokrue, PhD
- Protests, Racism and Our Children: Helping Kids Cope, ADAA blog post for parents, Michelle Witkin, PhD
- Addressing Systemic Racism in Action: Understanding the Mental Health Professionals’ Tools for Change, ADAA Blog Post for Therapists, Kimberyle Dean, PhD and Luana Marques, PhD
- NAMI: Indigenous Mental Health
- NAMI Indigenous Suicide Prevention
- Centers for Medicare & Medicaid AI/AN
- Indian Health Services, Behavioral Health
- StrongHearts Native Helpline
- Indigenous Story Studio (Canada-based)
- Healing Indigenous Lives Initiative – youth peer leadership program
- Centers for Medicare & Medicaid AI/AN
- Johns Hopkins Center for American Indian Health
- The Native Hope – Health and Wellness Blog
- One Sky Center - National Resource Center for American Indian and Alaska Native Health, Education, and Research
- WeRNative - health resource for Native youth, by Native youth
- Its Hard to Search for a Therapist of Color: These Website Want to Change That, NYTimes.com, July 2021
- People of Color Face Significant Barriers to Mental Health Services, CNN.com
- The effects of COVID-19 on the mental health of Indigenous communities
- Historical Trauma: The Confluence of Mental Health and History in Native American Communities
- Blog Post: Mental Health Issues from Historical Trauma Plague Native Americans
4. Health, United States 2017, US Department of Health and Human Services, CDC
6. Access to Mental Health Services at Indian Health Service and Tribal Facilities, US Department of Health and Human Services
7. Profile: American Indian/ Alaska Native, US Department of Health and Human Services Office of Minority Health
8. Mental Health: Culture, Race, and Ethnicity: A Supplement of Mental Health: A Report of the Surgeon General, US Department of Health and Human Services
9. Understanding Depression in Aboriginal Communities and Families, National Collaborating Centre for Aboriginal Health
10. Suicide Rates for Females and Males by Race and Ethnicity: United States, 1999 and 2017, CDC
11. Walls, M., Sittner, K.J., Whitbeck, L.B. et al. Prevalence of Mental Disorders from Adolescence Through Early Adulthood in American Indian and First Nations Communities. Int J Ment Health Addiction 19, 2116–2130 (2021). https://doi.org/10.1007/s11469-020-00304-1
12. Kading ML, Hautala DS, Palombi LC, Aronson BD, Smith RC, Walls ML. Flourishing: American Indian Positive Mental Health. Soc Ment Health. 2015 Nov;5(3):203-217. doi: 10.1177/2156869315570480. Epub 2015 Feb 2. PMID: 28966866; PMCID: PMC5619867.
13. Coser A, Kominsky TK, White EJ. For the Good of the Community: Considering the Impact of Evidence-Based Treatment Adaptation on Tribal Communities. Behav Ther (N Y N Y). 2021;44(4):161-170.